Use of a glucocorticoid receptor ii antagonist to treat depression in patients taking il-2

ABSTRACT

The invention pertains to the discovery that type II glucocorticoid receptor antagonists can be used in methods for reversing or inhibiting the symptoms of depression in patients receiving interleukin-2 treatment.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application claims benefit of U.S. Provisional Application No.60/797,265, filed May 2, 2006, which is herein incorporated by referencein its entirety.

FIELD OF INVENTION

This invention relates to the use of glucocorticoid receptor antagonistsas a method for ameliorating the symptoms of depression in a patienttaking interleukin-2 (IL-2).

BACKGROUND OF THE INVENTION

Cytokines are small protein molecules that are actively secreted byimmune cells and other cell types. Cytokines function to orchestrateimmune system responses and coordinate those responses with otherphysiological systems in the body. Their action is often local, but caneffect the whole body, including the nervous system. Common examples ofcytokines include interferon-α (IFNα), IFNβ, IFNγ, interleukin-1 (IL-1),IL-2, IL-6, IL-10, granulocyte macrophage-colony stimulating factor(GM-CSF), and tumor necrosis factor-α (TNF-α).

Cytokines have been shown to be effective in the treatment of a varietyof medical conditions, such as hepatitis C, multiple sclerosis, certaininfections, leukemia, Kaposi's sarcoma, melanoma, myeloma, renalcarcinoma, and other forms of cancer. The most commonly used cytokinesfor medical therapy include IL-2, IFNα, β, and γ. See, e.g., Dunn etal., Neurosci. and Behav. Rev. 29:891-909 (2005).

IL-2 is a potent immune stimulator activating diverse cells in theimmune system, including T cells, B cells and monocytes. IL-2 is apotent and critical stimulator for T cell proliferation. IL-2 stimulatesthe cytolytic activity of NK cells and stimulates the secretion ofadditional cytokines, including IFNγ, GM-CSF, and TNF-α. IL-2 alsoenhances the proliferation and antibody secretion by normal B-cells, andstimulates the cytotoxic activities of activated macrophages, promotingthe further secretion of TNF-α, IL-1 and IL-6. It was by virtue of theseactivities that IL-2 was tested and approved for the treatment ofcancer. IL-2 has been used as a therapeutic agent for the treatment ofvarious forms of cancer since 1981, and has been shown to be effectivefor the treatment of renal cell carcinoma, and metastatic melanoma insome patients (see, e.g., Wichers and Maes, Int. J. Neuropsychopharm.5:375-388 (2002)). Each of the cytokines commonly used for medicaltreatment, however, is reported to produce side-effects such asasthenia, myalgia, confusion, and influenza-like symptoms. Depression ismost commonly associated with IFNα and IL-2, and occasionally with IFNβ(see Dunn et al., supra).

Depression may be caused by cytokine secretion associated with anactivation of the immune system. The incidence of immune abnormalitiesis higher in depressed patients as compared to the general population,and depression is a common side-effect of cytokine therapy (Dunn et al.,supra).

Clinical observations have indicated that patients being treated withinterferons or IL-2 display influenza like symptoms and nonspecificneuropsychiatric symptoms, some of which are characteristic ofdepression. In animal studies, immune activation and administration ofthe bacterial endotoxin lipopolysacchamide (LPS) or IL-1 can induce abehavioral pattern resembling that commonly observed in sick animals,including humans. This behavioral pattern is known as sickness behavior,and shares many of the symptoms of depression and anxiety that may beattenuated by antidepressant agents (See, e.g., Anisman and Merali,Annal. of Med. 35:2-11 (2003)).

Furthermore, IL-2 may induce anhedonic effects, a prominent feature ofdepression. Depressive illness is accompanied by signs of immuneactivation and elevated cytokine production or elevated levels ofcirculating cytokines, particularly IL-2, IL-1, IL-6, TNF-α, and IFN-γ.In addition, immunotherapy with IL-2 or IFN-α may result in adepression-like state that may be attenuated by treatment with anantidepressant.

Cortisol acts by binding to an intracellular glucocorticoid receptor(GR). In humans, glucocorticoid receptors are present in two forms: aligand-binding GR-alpha of 777 amino acids; and a GR-beta isoform thatdiffers in only the last fifteen amino acids. The two types of GR havehigh affinity for their specific ligands, and are considered to functionthrough the same signal transduction pathways.

Hypercortisolism has been observed in depressed patients.Glucocorticoids (GC) are reported to suppress long-term potentiation,inhibit neurogenesis, and stimulate excitatory amino acidneurotransmitter release, which causes hippocampal atrophy and memoryimpairment. (See, e.g., Song, Brain Behav. Immun. 16:557-568 (2002)).Similar effects have been reported with pro-inflammatory cytokines, suchas IL-1β (Song, 2002, supra). It is also well established thatpro-inflammatory cytokines directly stimulate the hypothalamic-pituitaryadrenal (HPA) axis to secrete cortisol, significantly increasing GCsecretion (See, e.g., Song, 2002, supra; Connor et al., Neuroscience84:923-933 (1998)). In fact, studies in rats suggest that the IL-1induced memory deficits are related to the effect of IL-1 on CRF andGCs. In these studies, rats that were given an intracerebroventricular(i.c.v.) injection of the GC antagonist RU486 immediately prior toreceiving administration of IL-1 showed significant reduction inlearning and memory impairments typically associated with IL-1administration. Furthermore, rats that did not recover from thedeleterious effects of IL-1, even after several days, showed completerecovery after one or two treatments with RU486. These studies stronglysupport the notion that GCs mediate the effect of IL-1 on learning andmemory (Song, 2002, supra).

The biological effects of cortisol, including pathologies ordysfunctions caused by hypercortisolemia, can be modulated andcontrolled at the GR level using receptor antagonists. Several differentclasses of agents are able to act as GR antagonists, i.e., to block thephysiologic effects of GR-agonist binding (the natural agonist iscortisol). These antagonists include compositions that, by binding toGR, block the ability of an agonist to effectively bind to and/oractivate the GR. One family of known GR antagonists, mifepristone andrelated compounds, are effective and potent anti-glucocorticoid agentsin humans (Bertagna, J. Clin. Endocrinol. Metab. 59:25, 1984).Mifepristone binds to the GR with high affinity, with a K ofdissociation <10⁻⁹ M (Cadepond, Annu. Rev. Med. 48:129, 1997). Thus, inone embodiment of the invention, mifepristone and related compounds areused to ameliorate the symptoms of depression associated with IL-2therapy.

Previous studies have suggested that hypercortisolemia is a commonfeature of major depression (Murphy J. Steroid Biochem Mol. Biol.38:537-558 (1991)). Furthermore, major depression that is resistant toconventional therapy has been shown to respond to inhibitors of steroidbiosynthesis (Murphy J. Steroid Biochem Mol. Biol. 39:239-244 (1991);U.S. Pat. No. 4,814,333). These studies prompted a further investigationto examine the effects of the glucocorticoid receptor antagonist RU486as a treatment for severe major depression of very long standing inpatients who were extremely resistant to treatment (Murphy J Psych andNeurosci. 18(5):209-213 (1993)). This study, which purports to examinethe effects of RU486 on patients with severe major depression containedfour patients, only one of which completed the treatment. In addition,the study, which did not contain a control group against which theresults could be measured, showed no clear evidence that RU486 waseffective in treating depression.

The results obtained by Murphy, et al., do however, suggest that themethods described in U.S. Pat. No. 4,814,333 would not be effective intreating patients suffering from IL-2 induced depression. Furthermore,the patients treated by the methods disclosed in Murphy and U.S. Pat.No. 4,814,333 can be distinguished from the methods described herein, inthat the present methods are directed toward treatment of patients notsuffering from depression and having normal cortisol levels at the timeIL-2 therapy is commenced.

Symptoms of depression can be detected by various methods wellestablished in the art, including regular physical examinations andneuropsychiatric examinations (e.g. Hamilton Rating Scale). Certainlaboratory tests can also facilitate the diagnosis and assessment ofdepression. Description of detailed diagnostic methods and criteria canbe found in a number of publications in the art. One such example isDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition(DSM-IV).

Many of the actions of cortisol in the brain are mediated by binding tothe type I (mineralocorticoid) receptor, which is preferentiallyoccupied, relative to the type II (glucocorticoid) receptor, atphysiological cortisol levels (Ron de Kloet, et al., Trends in Neurosci.22(10):422-426 (1999)). As cortisol levels increase, more glucocorticoidreceptors are occupied and activated. Because cortisol plays anessential role in metabolism, inhibition of all cortisol-mediatedactivities, however, would be fatal. Therefore, antagonists thatspecifically prevent type II glucocorticoid receptor functions but donot antagonize type I mineralocorticoid receptor functions are ofparticular use in this invention. Mifepristone and similar antagonistsare examples of this category of receptor antagonists.

While there is strong evidence to suggest that cytokines such as IL-2can contribute to depression, it is notable that neither acute norrepeated administration of IL-2 influences the plasma levels ofcorticosterone. (See, e.g., Anisman and Merali, 2003, supra; Lacosta, etal., Neuroimmunomod. 9:1-16 (2000); Song, 2002, supra). Given themultitude of effects of IL-2, and the fact that IL-2 does not effect theplasma or brain levels of cortisol, it is surprising that the symptomsof depression associated with IL-2 therapy are ameliorated by treatmentwith glucocorticoid receptor antagonists.

For IL-2 therapy to be maximally beneficial, the adverse side effects,especially those associated with depression, must be minimized. Thepresent inventors have determined that glucocorticoid receptorantagonists such as mifepristone are effective agents for amelioratingthe symptoms of depression in patients undergoing IL-2 therapy, who arenot otherwise clinically depressed and are not taking type IIglucocorticoid receptor antagonists for another reason. The presentinvention therefore fulfills the need for an effective measure forpreventing or delaying the onset of the symptoms of depressionassociated with IL-2 therapy, or for ameliorating or reversing thesymptoms of depression associated with IL-2 therapy, by providingmethods of administering glucocorticoid receptor antagonists to patientsundergoing IL-2 therapy.

BRIEF SUMMARY OF THE INVENTION

The invention provides a method of ameliorating the symptoms ofdepression in a patient taking IL-2 and having normal cortisol levelsand not suffering from clinical depression, as diagnosed by aprofessional, at the time IL-2 therapy is commenced. The methodcomprises administration of a therapeutically effective amount of aglucocorticoid receptor antagonist to the patient, with the proviso thatthe patient is not otherwise suffering from a disease for whichtreatment using glucocorticoid receptor antagonists is indicated.

In one embodiment of the invention, the method of ameliorating thesymptoms of depression is achieved by administering the glucocorticoidreceptor antagonist to the patient undergoing IL-2 therapy.

In another embodiment of the invention, a glucocorticoid receptorantagonist is co-administered to the patient concomitantly with the IL-2therapy.

In another embodiment of the invention, the glucocorticoid receptorantagonist is administered to the patient throughout the course of theIL-2 therapy.

In another embodiment of the invention, the GRA is administered to thepatient taking IL-2 in conjunction with other treatment methods.

In another embodiment of the invention, the GRA is a steroid compound.

In another embodiment of the invention, the GRA has a cortisol steroidbackbone with one of the following modifications or derivatives: removalof the 11-β-hydroxy group, aryl substitution of the 11-β-hydroxy group,11-β-phenyl-aminodimethyl steroids, 17-β-side chain modifications,alpha-keto-methane-sulfonate derivatives, and androgen type steroids.Examples of such compounds include dexamethasone-oxetanone,4-pregnene-11-beta,17-alpha,21-triol-3,20-dione-21-methane-sulfonate,16-methyl-9alpha-fluoro-1,4-pregnadiene-11β,17-alpha,21-triol-3,20-dione-21-methane-sulfonate,11-β-(4-dimethyl-aminoethoxyphenyl)-17-alpha-(propynyl-17-beta-hydroxy-4,9-estradien-3-one,and17-β-hydroxy-11-β-(4-dimethyl-aminophenyl)17-alpha-(1-propynyl)estra-4,9-dien-3-one.

In another embodiment of the invention, the glucocorticoid receptorantagonist comprises a steroidal skeleton with at least onephenyl-containing moiety in the 11-beta position of the steroidalskeleton. The phenyl-containing moiety in the 11-beta position of thesteroidal skeleton can be a dimethylaminophenyl moiety. An example ofsuch a glucocorticoid receptor antagonist would be mifepristone, RU009and RU044.

In another embodiment of the invention, the glucocorticoid receptorantagonist includes any steroid backbone modification which effects abiological response resulting from a GR agonist interaction. Examples ofGR antagonists known in the art are discussed in more detail below, butinclude (6β,11β,17β)-11-(4-dimethyl-aminophenyl)-6methyl-4′,5′-dihydro[estra-4,9-diene-17,2′(3H′)-furan]-3-one (“Org31710”, see Mizutani, J Steroid Biochem Mol Biol 42(7):695-704, 1992),Org31806, Org34517, Org34116, RU43044,(17-beta-hydroxy-11-beta-/4-/[methyl]-[1-methylethyl]aminophenyl/-17alpha-[prop-1-ynyl]estra-4-9-diene-3-one (“RU40555”, see Kim, J SteroidBiochem Mol Biol. 67(3):213-22, 1998), RU28362, and ZK98299.

In another embodiment of the invention, the GRA is steroid compoundwhich effects a biological response resulting from a GR agonistinteraction. Examples of compounds known in the art, and discussed inmore detail below, include(6β,11β,17β)-11-(4-(dimethyl-amino)phenyl)-6-methyl-4′,5′-dihydro[estra-4,9-diene-17,2′(3H)-furan]-3-one,(11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)e-stra-4,9-dien-3-one,(11β,17α)-11-(4-acetylphenyl)-17,23-epoxy-19,24-dinorchola-4,-9,20-trien-3-one,(7β,11β,17β)-11-(4-(dimethylamino)phenyl)-7-Me-4′,5′-dihydrospiro(oestra-4,9-diene-17,2′(3′H)-furan)-3-one]-,(11β,17α)-11,21-Bis[4-(dimethylamino)phenyl]-17-hydroxy-19-norpregna-4,9,dien-20-yn-3-one,and(11β,17α)-11-[4-(dimethylamino)phenyl]-17-hydroxy-21-[4-(methylsulfonyl)phenyl-19-norpregna-4,9-dien-20-yn-3-one.

In yet another embodiment of the invention, the GRA is mifepristone.

In another embodiment of the invention, the GRA is a non-steroidalcompound that effects a biological response resulting from a GR agonistinteraction by interfering with the binding between the agonist and GR.Examples of compounds known in the art, and discussed in more detailbelow, include:4b(S)-benzyl-7(S)-hydroxy-7-(1-propynyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (pyridine-4-ylmethyl)amide,4b(S)-benzyl-7(S)-hydroxy-7-(3,3,3-trifluoropropyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (2-methylpyridin-3-ylmethyl)amide,1-(o-chloro-alpha,alpha-diphenylbenzyl)imidazole,N(triphenylmethyl)imidazole, N-([2-fluoro-9-phenyl]fluorenyl)imidazole,N-([2-pyridyl]diphenylmethyl)imidazole,N-([4,4′,4″]-trichlorotrityl)imidazole, and N((2,6dichloro-3-methylphenyl)diphenyl)methylimidazole.

In yet another embodiment of the invention, the non-steroidal compoundis derived from a chemical class known to give rise compounds thataffect a biological response resulting from a GR agonist interaction.Examples of such groups from which GRA for use with the invention arediscussed more fully below, but include 6-substituted-1,2-dihydro-Nprotected-quinolines, octahydrophenanthrenyl carbamates,oxadiazolylalkoxyoctahydrophenanthrenes, and octahydrophenanthrenehydrazines, octahydro-2-H-naphthol[1,2,-f]indole-4 carboxamide,cyclopent[f]indazole, and benz[f]indazole, 6H-dibenzo[b,d]pyranderivatives, substituted aminobenzene derivatives, triphenylmethanederivatives, diphenyl ether derivatives, and modified pyrimidinecompounds. Examples of non-steroid GRA's known in the art that aresuitable for use with the invention and discussed more fully belowinclude: 1-(2-chlorotrityl)-2-methylimidazole,N-(2-chlorotrityl)-L-prolinol acetate,1-(2-chlorotrityl)-1,2,4-triazole, and1-(2-chlorotrityl)-3,5-dimethylpyrazole,cis-1-acetyl-4-(4-((2-(2,4-dichlorophenyl)-2-(1H-imidazol-1-ylmethyl)-1,3-dioxolan-4-yl)methoxy)phenyl)piperazine,N-(2[4,4′,4″-trichlorotrityl]oxyethyl)morpholine,1-(2[4,4′,4″-trichlorotrityl]oxyethyl)-4(2-hydroxyethyl)piperazinedimaleate, 4-(morpholinomethyl)-A-(2-pyridyl)benzhydrol, and1,S-bis(4,4′,4″-trichlorotrityl)-1,2,4-triazole-3-thiol,9-(3-mercapto-1,2,4 triazolyl)-9-phenyl-2,7-difluorofluorenone,5-(5-methoxy-2-(N-methylcarbamoyl)-phenyl)dibenzosuberol,4a(S)-benzyl-2(R)-chloroethynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol,and4a(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol.

In another embodiment of the invention, the glucocorticoid receptorantagonist comprises a non-steroidal compound. Examples of non-steroidalGR antagonist compounds, and modified pyrimidine compounds as disclosedin PCT US05/23675.

In other embodiments of the invention, the GRA is administered in adaily amount of between 0.5 mg and 20 mg per kg of body weight per day,preferably between about 1 mg and 10 mg per kg of body weight per day,or preferably between 1 mg and 4 mg per kg of body weight per day,preferably. The invention further provides that the GRA is administeredonce per day and/or where administration is oral, by a transdermalapplication, by a nebulized suspension, by an aerosol spray, or byinjection, or by an intravaginal or intrarectal route, includingsuppositories.

In another embodiment of the invention, the glucocorticoid receptorantagonist is an azadecalin or a fused ring azadecalin compounds knownin the art, discussed in more detail below, but those compoundsdisclosed in U.S. Pat. App. 20040176595, azadecalin and relatedcompounds disclosed in PCT/US05/08049 having the general formula:

In formula (I), L¹ and L² are members independently selected from abond, substituted or unsubstituted alkylene, and substituted orunsubstituted heteroalkylene. The dashed line b is optionally a bond.Ring A is a member selected from substituted or unsubstituted 5 to 6membered heterocycloalkyl, and substituted or unsubstituted heteroaryl.R¹ is a member selected from substituted or unsubstituted higher alkyl,substituted or unsubstituted heteroalkyl, substituted or unsubstitutedcycloalkyl, substituted or unsubstituted heterocycloalkyl, substitutedor unsubstituted aryl, substituted or unsubstituted heteroaryl, and—OR^(1A). R^(1A) is a member selected from substituted or unsubstitutedalkyl, substituted or unsubstituted heteroalkyl, substituted orunsubstituted cycloalkyl, substituted or unsubstituted heterocycloalkyl,substituted or unsubstituted aryl, and substituted or unsubstitutedheteroaryl; and R² is a member selected from substituted orunsubstituted alkyl, substituted or unsubstituted heteroalkyl,substituted or unsubstituted cycloalkyl, substituted or unsubstitutedheterocycloalkyl, substituted or unsubstituted aryl, substituted orunsubstituted heteroaryl, —S(O₂)R^(2A), S(O₂)NR^(2B)R^(2C), ═NOR^(2D).R^(2A), R^(2B), R^(2C), and R^(2D) are members independently selectedfrom substituted or unsubstituted alkyl, substituted or unsubstitutedheteroalkyl, substituted or unsubstituted cycloalkyl, substituted orunsubstituted heterocycloalkyl, substituted or unsubstituted aryl, andsubstituted or unsubstituted heteroaryl.

In other embodiments of the invention, the glucocorticoid receptorantagonist is administered in a daily amount of between about 0.5 toabout 20 mg per kilogram of body weight per day, preferably betweenabout 1 to about 10 mg per kilogram of body weight per day or preferablybetween about 1 to about 4 mg per kilogram of body weight per day. Theinvention further provides for methods where the GRA is administeredonce a day and/or where the GRA is administered by mouth (orally), bytransdermal application, by a nebulized suspension, by an aerosol spray,by injection, or by an intraocular, intravaginal intrarectal route,including suppositories.

A further understanding of the nature and advantages of the presentinvention is realized by reference to the remaining portions of thespecification and claims.

All publications, patents, and patent applications cited herein arehereby expressly incorporated by reference for all purposes.

DETAILED DESCRIPTION OF THE INVENTION

This invention pertains to the surprising discovery that agents capableof inhibiting glucocorticoid-induced biological responses are effectivefor ameliorating the symptoms of depression in patients taking IL-2. Inpatients who are to begin, or are currently undergoing, or havecompleted IL-2 therapy, the methods of the invention can ameliorate thesymptoms of depression associated with IL-2 therapy. The methods of theinvention are effective in ameliorating the symptoms of depressionassociated with IL-2 therapy in a patient afflicted with either normal,increased, or decreased levels of cortisol or other glucocorticoids,natural or synthetic.

As the methods of the invention include the use of any means tointerfere with the binding between an agonist and GR and to thereforeinhibit the downstream biological effects, illustrative compounds andcompositions that can be used to treat depression induced by IL-2treatment are also set forth. Routine procedures that can be used toidentify further compounds and compositions able to block the biologicalresponse caused by a GR-agonist interaction for use in practicing themethods of the invention are also described. As the invention providesfor administering these compounds and compositions as pharmaceuticals,routine means to determine GR antagonist drug regimens and formulationsto practice the methods of the invention are set forth below.

I. DEFINITIONS

As used herein, the term “ameliorating the symptoms of depression”refers to: (1) preventing or delaying the onset of symptoms ofdepression associated with IL-2 administration in a patient beingtreated with IL-2, but does not yet experience or exhibit symptoms ofdepression (prophylactic treatment), or (2) inhibiting the symptoms ofdepression and any further development of the symptoms to provide relieffrom the symptoms or side effects of depression (including palliativetreatment), or (3) reversing the symptoms of depression (causingregression of the symptoms of depression). Amelioration of the symptomsof depression can be based on objective or subjective parameters,including the results of a physical examination, a neuropsychiatricexamination, and/or a psychiatric evaluation.

The term “Interleukin-2” is used synonymously with “IL-2.” As usedherein, IL-2 refers to a protein whether native, recombinant, or made ina laboratory (e.g., aldesleukin), having the 133 normally occurringamino acid sequence of a native human IL-2 (less the signal peptide,consisting of an additional 20 N-terminal amino acids), whose amino acidsequence is described in Fujita, et al., PNAS USA, 80:7437-7441 (1983),with or without an additional N-terminal methionine which is necessarilyincluded when the protein is expressed as an intracellular fraction inE. coli, or biologically active fragments, or variants thereof.

IL-2 may be used to treat cancer (e.g. metastatic melanoma or renalcarcinoma), or other diseases known in the art. Properties displayed byIL-2 include but are not limited to: enhancing the ability: of thebody's immune system to fight disease; to kill tumor cells; to stimulatethe cytolytic activity of NK cells; and to stimulate the secretion ofadditional cytokines including IFNγ, GM-CSF, and TNFα, IL-1 and IL-6.

IL-2 can also be defined by its ability to be bound by antibodiesmanufactured to recognize IL-2. Examples of commercially availableantibodies that bind human IL-2 include: 4IL34, HyTest Ltd., TurkuFinland; GTX74203, GTX75071, GeneTex, Inc., San Antonio, Tex.;855.020.005, Diaclone, Stamford, Conn.; XP-5182, ProSci, Inc., Poway,Calif.; ab10751, Abcam, Inc., Cambridge, UK.; ab16235, NovusBiologicals, Littleton, Colo.

IL-2 can also be defined by its ability to binds an IL-2 receptor asdisclosed in U.S. Pat. No. 6,955,807. Furthermore, IL-2 can be definedby its biological activity using any suitable assay known in the art.Example of such assays include PHA blast proliferation and NK cellproliferation assays as disclosed in U.S. Pat. No. 6,955,807.

IL-2 as used herein is also includes biologically active fragments orvariants of IL-2 that show substantial relative activity compared tonative IL-2. For example, compounds that show full activity when boundto cells expressing the IL-2 receptor αβγ, but reduced activity on cellsbearing IL-2 receptor βγ (e.g., NK cells) are deemed IL-2 as definedherein. Examples of IL-2 variants that meet this definition of IL-2 aredisclosed in U.S. Pat. No. 6,559,807.

The term “depression” includes any form of depression as clinicallydiagnosed by a professional. For instance, this term encompasses majordepression, which is characterized by the presence of five or more ofthe following symptoms for at least 2 weeks: trouble sleeping orexcessive sleeping; a dramatic change in appetite, often with weightgain or loss; fatigue and lack of energy; feelings of worthlessness,self-hate, and inappropriate guilt; extreme difficulty concentrating;agitation, restlessness, and irritability; inactivity and withdrawalfrom usual activities, a loss of interest or pleasure in activities thatwere once enjoyed (e.g., sexual intercourse); feelings of hopelessnessand helplessness; and thoughts of death or suicide.

The term depression also encompasses dysthymia, a chronic form ofdepression, characterized by moods that are consistently low, but not asextreme as other types of depression. Patients affected by dysthymiastruggle nearly every day with low self-esteem, despair, andhopelessness. The main symptom of dysthymia is low, dark, or sad moodnearly every day for at least 2 years. Other symptoms can include: poorappetite or overeating; insomnia or hypersomnia; low energy or fatigue;low self-esteem; poor concentration; and feelings of hopelessness.

The term depression also encompasses minor depression, which includesdisorders with depressive features that do not meet the criteria for anyspecific mood disorder or adjustment disorder with depressed mood.Examples of minor depression may include but are not limited to arecurrent, mild, depressive disturbance that does not meet the criteriafor dysthymia; or non-stress-related depressive episodes that do notmeet the criteria for a major depressive episode.

The term “cortisol” refers to a family of compositions also referred toas hydrocortisone, and any synthetic or natural analogues thereof.Normal cortisol levels fluctuate throughout the day, typically beingless than 25 mg/dl in the morning, and between 5-15 mg/dl in theafternoon.

The term “glucocorticoid receptor (GR)” refers to a family ofintracellular receptors also referred to as the cortisol receptor, whichspecifically bind to cortisol and/or cortisol analogs. The term includesisoforms of GR, recombinant GR, and mutated GR.

The term “mifepristone” refers to a family of compositions also referredto as RU486, or RU38.486, or17-beta-hydroxy-11-beta-(4-dimethyl-aminophenyl)-17-alpha-(1-propynyl)-estra-4,9-dien-3-one),or11-beta-(4-dimethylaminophenyl)-17-beta-hydroxy-17-alpha-(1-propynyl)-estra-4,9-dien-3-one),or analogs thereof, which bind to the GR, typically with high affinity,and inhibit the biological effects initiated/mediated by the binding ofany cortisol or cortisol analogue to a GR receptor. Chemical names forRU-486 vary; for example, RU486 has also been termed:11β-(Dimethylamino)phenyl]-17β-hydroxy-17-(1-propynyl)-estra-4,9-dien-3-one;11β-(4-dimethyl-aminophenyl)-17β-hydroxy-17α-(prop-1-ynyl)-estra-4,9-dien-3-one;17β-hydroxy-11β-(4-dimethylaminophenyl-1)-17α-(propynyl-1)-estra-4,9-diene-3-one;17β-hydroxy-11β-(4-dimethylaminophenyl-1)-17α-(propynyl-1)-E;(11β,17β)-11-[4-dimethylamino)-phenyl]-17-hydroxy-17-(1-propynyl)estra-4,9-dien-3-one;and11β-[4-(N,N-dimethylamino)phenyl]-17α-(prop-1-ynyl)-D-4,9-estradiene-17β-ol-3-one.

The term “specific glucocorticoid receptor antagonist” refers to anycomposition or compound which partially or completely inhibits(antagonizes) the binding of a glucocorticoid receptor (GR) agonist,such as cortisol, or cortisol analogs, synthetic or natural, to a GR. By“specific,” it is intended that the drug to preferentially bind to theGR rather than the mineralocorticoid receptor (MR) with an affinity atleast 100-fold, and frequently 1000-fold.

A patient “not otherwise in need of treatment with a glucocorticoidreceptor antagonist” is a patient who is not suffering from a conditionthat is known in the art to be effectively treatable with glucocorticoidreceptor antagonists. Conditions known in the art to be effectivelytreatable with glucocorticoid receptor antagonists include Cushing'sdisease, drug withdrawal, psychosis, dementia, stress disorders, andpsychotic major depression.

In this application, when two therapeutic agents are “administeredcoextensively,” the administration time periods of the agents maycompletely overlap or at least in part overlap. When the administrationof the two agents is not coextensive, the two therapeutic agents arepreferably administered in time periods that do not overlap, but stillwithin each other's bioactive period, i.e., the earlier administeredagent retains at least a substantial portion of its biological activityin the patient at the time when the latter administered agent isdelivered. In other cases where two therapeutic agents are notadministered coextensively, however, the two agents may be administeredoutside of each other's bioactive period.

Where substituent groups are specified by their conventional chemicalformulae, written from left to right, they equally encompass thechemically identical substituents that would result from writing thestructure from right to left, e.g., —CH₂O— is equivalent to —OCH₂—.

The term “alkylene” by itself or as part of another substituent means adivalent radical derived from an alkane, as exemplified, but notlimited, by —CH₂CH₂CH₂CH₂—, and further includes those groups describedbelow as “heteroalkylene.” Typically, an alkyl (or alkylene) group willhave from 1 to 24 carbon atoms, with those groups having 10 or fewercarbon atoms being preferred in the present invention. A “lower alkyl”or “lower alkylene” is a shorter chain alkyl or alkylene group,generally having eight or fewer carbon atoms.

The term “alkyl,” by itself or as part of another substituent, means,unless otherwise stated, a straight (i.e., unbranched) or branchedchain, or cyclic hydrocarbon radical, or combination thereof, which maybe fully saturated, mono- or polyunsaturated and can include di- andmultivalent radicals, having the number of carbon atoms designated(i.e., C₁-C₁₀ means one to ten carbons). Examples of saturatedhydrocarbon radicals include, but are not limited to, groups such asmethyl, ethyl, n-propyl, isopropyl, n-butyl, t-butyl, isobutyl,sec-butyl, cyclohexyl, (cyclohexyl)methyl, cyclopropylmethyl, homologsand isomers of, for example, n-pentyl, n-hexyl, n-heptyl, n-octyl, andthe like. An unsaturated alkyl group is one having one or more doublebonds or triple bonds. Examples of unsaturated alkyl groups include, butare not limited to, vinyl, 2-propenyl, crotyl, 2-isopentenyl,2-(butadienyl), 2,4-pentadienyl, 3-(1,4-pentadienyl), ethynyl, 1- and3-propynyl, 3-butynyl, and the higher homologs and isomers. Alkyl groupsthat are limited to hydrocarbon groups are termed “homoalkyl”.

The term “heteroalkyl,” by itself or in combination with another term,means, unless otherwise stated, a stable straight or branched chain, orcyclic hydrocarbon radical, or combinations thereof, consisting of thestated number of carbon atoms and at least one heteroatom selected fromthe group consisting of O, N, P, Si, and S, and wherein the nitrogen andsulfur atoms may optionally be oxidized and the nitrogen heteroatom mayoptionally be quaternized. The heteroatom(s) O, N, P, S, and Si may beplaced at any interior position of the heteroalkyl group or at theposition at which the alkyl group is attached to the remainder of themolecule. Examples include, but are not limited to, —CH₂—CH₂—O—CH₃,—CH₂—CH₂—NH—CH₃, —CH₂—CH₂—N(CH₃)—CH₃, —CH₂—S—CH₂—CH₃, —CH₂—CH₂,—S(O)—CH₃, —CH₂—CH₂—S(O)₂—CH₃, —CH═CH—O—CH₃, —Si(CH₃)₃, —CH₂—CH═N—OCH₃,—CH═CH—N(CH₃)—CH₃, O—CH₃, —O—CH₂—CH₃, and —CN. Up to two heteroatoms maybe consecutive, such as, for example, —CH₂—NH—OCH₃ and —CH₂—O—Si(CH₃)₃.Similarly, the term “heteroalkylene” by itself or as part of anothersubstituent means a divalent radical derived from heteroalkyl, asexemplified, but not limited by, —CH₂—CH₂—S—CH₂CH₂— and—CH₂—S—CH₂—CH₂—NH—CH₂—. For heteroalkylene groups, heteroatoms can alsooccupy either or both of the chain termini (e.g., alkyleneoxy,alkylenedioxy, alkyleneamino, alkylenediamino, and the like). Stillfurther, for alkylene and heteroalkylene linking groups, no orientationof the linking group is implied by the direction in which the formula ofthe linking group is written. For example, the formula —C(O)₂R′represents both —C(O)₂R′ and —R′C(O)₂. As described above, heteroalkylgroups, as used herein, include those groups that are attached to theremainder of the molecule through a heteroatom, such as —C(O)R′,—C(O)NR′, —NR′R″, —OR′, —SR′, and/or —SO₂R′. Where “heteroalkyl” isrecited, followed by recitations of specific heteroalkyl groups, such as—NR′R″ or the like, it will be understood that the terms heteroalkyl and—NR′R″ are not redundant or mutually exclusive. Rather, the specificheteroalkyl groups are recited to add clarity. Thus, the term“heteroalkyl” should not be interpreted herein as excluding specificheteroalkyl groups, such as —NR′R″ or the like.

Unless otherwise explicitly stated, the terms “cycloalkyl” and“heterocycloalkyl,” by themselves or in combination with other terms,represent cyclic versions of “alkyl” and “heteroalkyl,” respectively.Additionally, for heterocycloalkyl, a heteroatom can occupy the positionat which the heterocycle is attached to the remainder of the molecule.Examples of cycloalkyl include, but are not limited to, cyclopentyl,cyclohexyl, 1-cyclohexenyl, 3-cyclohexenyl, cycloheptyl, and the like.Examples of heterocycloalkyl include, but are not limited to,1-(1,2,5,6-tetrahydropyridyl), 1-piperidinyl, 2-piperidinyl,3-piperidinyl, 4-morpholinyl, 3-morpholinyl, tetrahydrofuran-2-yl,tetrahydrofuran-3-yl, tetrahydrothien-2-yl, tetrahydrothien-3-yl,1-piperazinyl, 2-piperazinyl, and the like.

The term “aryl” means, unless otherwise stated, a polyunsaturated,aromatic, hydrocarbon substituent that can be a single ring or multiplerings (preferably from 1 to 3 rings) which are fused together or linkedcovalently. The term “heteroaryl” refers to aryl groups (or rings) thatcontain from one to four heteroatoms selected from N, O, and S, whereinthe nitrogen and sulfur atoms are optionally oxidized, and the nitrogenatom(s) are optionally quaternized. A heteroaryl group can be attachedto the remainder of the molecule through a carbon or heteroatom.Non-limiting examples of aryl and heteroaryl groups include phenyl,1-naphthyl, 2-naphthyl, 4-biphenyl, 1-pyrrolyl, 2-pyrrolyl, 3-pyrrolyl,3-pyrazolyl, 2-imidazolyl, 4-imidazolyl, pyrazinyl, 2-oxazolyl,4-oxazolyl, 2-phenyl-4-oxazolyl, 5-oxazolyl, 3-isoxazolyl, 4-isoxazolyl,5-isoxazolyl, 2-thiazolyl, 4-thiazolyl, 5-thiazolyl, 2-furyl, 3-furyl,2-thienyl, 3-thienyl, 2-pyridyl, 3-pyridyl, 4-pyridyl, 2-pyrimidyl,4-pyrimidyl, 5-benzothiazolyl, purinyl, 2-benzimidazolyl, 5-indolyl,1-isoquinolyl, 5-isoquinolyl, 2-quinoxalinyl, 5-quinoxalinyl,3-quinolyl, and 6-quinolyl.

Each of the above terms (e.g., “alkyl,” “heteroalkyl,” “aryl,” and“heteroaryl”) are meant to include both substituted and unsubstitutedforms of the indicated radical. Preferred substituents for each type ofradical are provided below.

Substituents for the alkyl and heteroalkyl radicals (including thosegroups often referred to as alkylene, alkenyl, heteroalkylene,heteroalkenyl, alkynyl, cycloalkyl, heterocycloalkyl, cycloalkenyl, andheterocycloalkenyl) can be one or more of a variety of groups selectedfrom, but not limited to: —OR′, ═O, ═NR′, ═N—OR′, —NR′R″, —SR′,-halogen, —SiR′R″R′″, OC(O)R′, —C(O)R′, —CO2R′, —CONR′R″, —OC(O)NR′R″,—NR″C(O)R′, NR′C(O)NR″R′″, —NR″C(O)2R′, —NR—C(NR′R″R′″)═NR″″,NRC(NR′R″)═NR′″, —S(O)R′, —S(O)₂R′, —S(O)₂NR′R″, NRSO₂R′, —CN and —NO₂in a number ranging from zero to (2m′+1), where m′ is the total numberof carbon atoms in such radical. R′, R″, R′″ and R″″ each preferablyindependently refer to hydrogen, substituted or unsubstitutedheteroalkyl, substituted or unsubstituted cycloalkyl, substituted orunsubstituted heterocycloalkyl, substituted or unsubstituted aryl (e.g.,aryl substituted with 1-3 halogens), substituted or unsubstituted alkyl,alkoxy or thioalkoxy groups, or arylalkyl groups. When a compound of theinvention includes more than one R group, for example, each of the Rgroups is independently selected as are each R′, R″, R′″ and R″″ groupswhen more than one of these groups is present. When R′ and R″ areattached to the same nitrogen atom, they can be combined with thenitrogen atom to form a 4-, 5-, 6-, or 7-membered ring. For example,—NR′R″ is meant to include, but not be limited to, 1-pyrolidinyl and4-morpholinyl. From the above discussion of substituents, one of skillin the art will understand that the term “alkyl” is meant to includegroups including carbon atoms bound to groups other than hydrogengroups, such as haloalkyl (e.g., —CF₃ and —CH₂CF₃) and acyl (e.g.,—C(O)CH₃, —C(O)CF₃, —C(O)CH₂OCH₃, and the like).

Similar to the substituents described for the alkyl radical,substituents for the aryl and heteroaryl groups are varied and areselected from, for example: halogen, OR′, —NR′R″, —SR′, -halogen,—SiR′R″R′″, OC(O)R′, —C(O)R′, CO2R′, —CONR′R″, —OC(O)NR′R″, —NR″C(O)R′,NR′C(O)NR″R′″, —NR″C(O)₂R′, NR—C(NR′R″R′″)═NR″″, NRC(NR′R″)═NR′″,—S(O)R′, —S(O)₂R′, —S(O)₂NR′R″, NRSO2R′, —CN and —NO₂, —R′, —N₃,—CH(Ph)₂, fluoro(C₁-C₄)alkoxy, and fluoro(C₁-C₄)alkyl, in a numberranging from zero to the total number of open valences on the aromaticring system; and where R′, R″, R′″ and R″″ are preferably independentlyselected from hydrogen, substituted or unsubstituted alkyl, substitutedor unsubstituted heteroalkyl, substituted or unsubstituted cycloalkyl,substituted or unsubstituted heterocycloalkyl, substituted orunsubstituted aryl and substituted or unsubstituted heteroaryl. When acompound of the invention includes more than one R group, for example,each of the R groups is independently selected as are each R′, R″, R′″and R″″ groups when more than one of these groups is present.

II. DETERMINATION OF DEPRESSIVE SYMPTOMS

Depression diagnosis is primarily based on examination of a patient, bya professional, for symptoms that are indicative of a clinicaldepression. An objective assessment of depression can be made usingrating scales known to persons of skill in the art (e.g., HamiltonRating Scale for Depression). See, J. Operational Psychiatry10(2):149-165 (1979). The depressive symptoms may represent either majorclinical depression, dysthymia, or minor depressive episodes, each ofwhich is discussed more fully below.

Major depression can be either a single episode or recurrent, which isthe presence of two or more major depressive episodes. The symptoms ofmajor depression cause clinically significant distress or impairment insocial, occupational, or other important areas of functioning. Adiagnosis of major depression is characterized by the presence of five(or more) symptoms during the same 2-week period and represents a changefrom previous functioning, and at least one of the symptoms must beeither a depressed mood, or a loss of interest or pleasure. Symptomscharacterizing major depression include: (1) depressed mood most of theday, nearly every day, as indicated by either a subjective report (e.g.,feeling sad or empty), or observations made by others, e.g., appearingtearful (in children and adolescents, the depressed mood can also be anirritable mood); (2) markedly diminished interest or pleasure in all, oralmost all, activities most of the day, nearly every day (as indicatedby either subjective account or observation made by others); (3)significant weight loss when not dieting, or weight gain (e.g., a changeof more than 5% of body weight in a month), or decrease or increase inappetite nearly every day (in children, failure to make expected weightgains should be considered); (4) insomnia or hypersomnia nearly everyday; (5) psychomotor agitation or retardation nearly every day(observable by others, not merely subjective feelings of restlessness orbeing slowed down); (6) fatigue or loss of energy nearly every day; (7)feelings of worthlessness or excessive or inappropriate guilt nearlyevery day (not merely self-reproach or guilt about being sick); (8)diminished ability to think or concentrate, or indecisiveness, nearlyevery day (either by subjective account or as observed by others); and(9) recurrent thoughts of death (not just fear of dying), recurrentsuicidal ideation without a specific plan, or a suicide attempt or aspecific plan for committing suicide.

A diagnosis of major depression requires that the patient not havepreviously experienced a manic episode, a mixed episode, or a hypomanicepisode. This exclusion, however, does not apply if all of themanic-like, mixed-like, or hypomanic-like episodes were substance ortreatment induced, or were due to the direct physiological effects of ageneral medical condition. Major depression is best characterized as notbeing better accounted for by schizoaffective disorder and is notsuperimposed on schizophrenia, schizophreniform disorder, delusionaldisorder, or a psychotic disorder not otherwise specified.

The symptoms of dysthymic disorder cause clinically significant distressor impairment in social, occupational, or other important areas offunctioning. Dysthymic disorder is best characterized as a depressedmood for most of the day, and for more days than not, as indicatedeither by a subjective account, or observation by others for at leasttwo years. In children and adolescents, the mood can manifest asirritability and the duration must be at least one year. In addition toa depressed mood, a diagnosis of dysthymic disorder requires thepresence of two (or more) of the following: poor appetite or overeating;insomnia or hypersomnia; low energy or fatigue; low self-esteem; poorconcentration or difficulty making decisions; and feelings ofhopelessness. During the two-year period of the disturbance for adults(one year for children or adolescents), the person has never beenwithout the symptoms for more than two months at a time. Furthermore, itmust be ruled out that the symptoms are not due to the directphysiological effects of a substance (e.g., a drug of abuse, amedication) or a general medical condition (e.g., hypothyroidism).

For a diagnosis of dysthymic disorder, the patient cannot haveexperienced a major depressive episode during the first two-years of thedysthymic disturbance (one year for children and adolescents). In otherwords, the disturbance is not better accounted for by chronic majordepressive disorder, or major depressive disorder, in partial remission.There may have been a previous major depressive episode provided therewas a full remission (no significant signs or symptoms for 2 months)before development of the dysthymic disorder. In addition, after theinitial 2 years (1 year in children or adolescents) of dysthymicdisorder, there may be superimposed episodes of major depressivedisorder, in which case both diagnoses may be give when the criteria aremet for a major depressive episode.

A diagnosis of dysthymic disorder requires that the patient not havepreviously experienced a manic episode, a mixed episode, or a hypomanicepisode, and criteria for cyclothymic disorder have not been met. Nor,does the disturbance occur exclusively during the course of a chronicpsychotic disorder, such as schizophrenia or delusional disorder.

Minor depression includes mood disorders with depressive features thatdo not meet the criteria for any specific mood disorder or adjustmentdisorder with depressed mood. Examples of minor depression may includebut are not limited to a recurrent, mild, depressive episode that doesnot meet the criteria for dysthymia, or a non-stress-related depressiveepisode that does not meet the criteria for a major depressive episode.

III. GENERAL LABORATORY PROCEDURES

When practicing the methods of the invention, a number of generallaboratory tests can be used to assist in the progress of the patientundergoing IL-2 therapy, including monitoring of parameters such asblood cortisol, drug metabolism, etc. These procedures can be helpfulbecause all patients metabolize and react to drugs uniquely. Inaddition, such monitoring may be important because each GR antagonisthas different pharmacokinetics. Patients with different medicalconditions may require different dosage regimens and formulations. Suchprocedures and means for determining dosage regimens and formulationsare well described in the scientific and patent literature.

A. Determining Blood Cortisol Levels

Varying levels of blood cortisol have been associated with IL-2-induceddepression, however, the invention may also be practiced upon patientswith apparently normal levels of blood cortisol. Thus, monitoring bloodcortisol and determining baseline cortisol levels are useful laboratorytests to assist in monitoring the progress of patients undergoing IL-2therapy. A wide variety of laboratory tests exist that can be used todetermine whether an individual is normal, hypo- or hypercortisolemic.Patients who are to receive or have been receiving long term IL-2treatment typically have normal levels of cortisol that are often lessthan 25 μg/dl in the morning, and frequently about 15 μg/dl or less inthe afternoon, which is considered to be at the high end of the normalrange of 5-15 μg/dl in the afternoon.

Immunoassays such as radioimmunoassays are commonly used because theyare accurate, easy to do and relatively cheap. Because levels ofcirculating cortisol are an indicator of adrenocortical function, avariety of stimulation and suppression tests, such as ACTH Stimulation,ACTH Reserve, or dexamethasone suppression (see, e.g., Greenwald, Am. J.Psychiatry 143:442-446, 1986), can also provide diagnostic, prognosticor other information to be used adjunctively in the methods of theinvention.

One such assay available in kit form is the radioimmunoassay availableas “Double Antibody Cortisol Kit” (Diagnostic Products Corporation, LosAngeles, Calif.), (Acta Psychiatr. Scand. 70:239-247, 1984). This testis a competitive radioimmunoassay in which ¹²⁵I-labeled cortisolcompetes with cortisol from a clinical sample for antibody sites. Inthis test, due to the specificity of the antibody and lack of anysignificant protein effect, serum and plasma samples require neitherpre-extraction nor pre-dilution.

B. Determination of Blood/Urine Mifepristone Levels

Because a patient's metabolism, clearance rate, toxicity levels, etc.differs with variations in underlying primary or secondary diseaseconditions, drug history, age, general medical condition and the like,it may be necessary to measure blood and urine levels of GR antagonist.Means for such monitoring are well described in the scientific andpatent literature. As in one embodiment of the invention, mifepristoneis administered to ameliorate the symptoms of depression in a patientundergoing IL-2 therapy, an illustrative example of determining bloodand urine mifepristone levels is set forth in the Example below.

C. Other Laboratory Procedures

Because the mechanism of depression associated with IL-2 therapy iscomplex and the symptoms may vary, a number of additional laboratorytests can be used adjunctively in the methods of the invention to assistin diagnosis, treatment planning, prognosis, toxicity, and the like. Forexample, diagnosis and treatment assessment can be augmented bymonitoring and measuring glucocorticoid-sensitive variables, includingbut not limited to fasting blood sugar, blood sugar after oral glucoseadministration, plasma concentrations thyroid stimulating hormone (TSH),corticosteroid-binding globulin, luteinizing hormone (LH),testosterone-estradiol-binding globulin, leptin, insulin, and/or totaland free testosterone.

Laboratory tests monitoring and measuring GR antagonist metabolitegeneration, plasma concentrations and clearance rates, including urineconcentration of antagonist and metabolites, may also be useful inpracticing the methods of the invention. For example, mifepristone hastwo hydrophilic, N-monomethylated and N-dimethylated, metabolites.Plasma and urine concentrations of these metabolites (in addition toRU486) can be determined using, for example, thin layer chromatography,as described in Kawai, Pharmacol. and Experimental Therapeutics241:401-406, 1987.

IV. GLUCOCORTICOID RECEPTOR ANTAGONISTS TO AMELIORATE SYMPTOMS OFDEPRESSION IN PATIENTS UNDERGOING IL-2 THERAPY

The invention provides for methods of inhibiting or reversing thesymptoms of depression induced by IL-2 therapy utilizing any compositionor compound that can block or interfere with the binding of cortisol ora cortisol analogue to a GR. Antagonists of GR activity utilized in themethods of the invention are well described in the scientific and patentliterature. A few illustrative examples are set forth below.

A. Steroidal Anti-Glucocorticoids as GR Antagonists

Steroidal glucocorticoid antagonists are administered to inhibit orreverse IL-2-induced depression in various embodiments of the invention.Steroidal antiglucocorticoids can be obtained by modification of thebasic structure of glucocorticoid agonists, i.e., varied forms of thesteroid backbone. The structure of cortisol can be modified in a varietyof ways. The two most commonly known classes of structural modificationsof the cortisol steroid backbone to create glucocorticoid antagonistsinclude modifications of the 11-beta hydroxy group and modification ofthe 17-beta side chain (see, e.g., Lefebvre, J. Steroid Biochem.33:557-563, 1989).

Examples of steroidal GR antagonists include androgen-type steroidcompounds as described in U.S. Pat. No. 5,929,058, and the compoundsdisclosed in U.S. Pat. Nos. 4,296,206; 4,386,085; 4,447,424; 4,477,445;4,519,946; 4,540,686; 4,547,493; 4,634,695; 4,634,696; 4,753,932;4,774,236; 4,808,710; 4,814,327; 4,829,060; 4,861,763; 4,912,097;4,921,638; 4,943,566; 4,954,490; 4,978,657; 5,006,518; 5,043,332;5,064,822; 5,073,548; 5,089,488; 5,089,635; 5,093,507; 5,095,010;5,095,129; 5,132,299; 5,166,146; 5,166,199; 5,173,405; 5,276,023;5,380,839; 5,348,729; 5,426,102; 5,439,913; 5,616,458, and 5,696,127.Such steroidal GR antagonists include cortexolone,dexamethasone-oxetanone, 19-nordeoxycorticosterone, 19-norprogesterone,cortisol-21-mesylate; dexamethasone-21-mesylate,11β-(4-dimethylaminoethoxyphenyl)-17α-propynyl-17β-hydroxy-4,9estradien-3-one (RU009), and17β-hydroxy-17α-19-(4-methylphenyl)androsta-4,9(11)-dien-3-one (RU044).

1. Removal or Substitution of the 11-Beta Hydroxy Group

Glucocorticoid agonists with modified steroidal backbones comprisingremoval or substitution of the 11-beta hydroxy group are administered inone embodiment of the invention. This class includes naturalantiglucocorticoids, including cortexolone, progesterone andtestosterone derivatives, and synthetic compositions, such asmifepristone (Lefebvre et al., supra). Preferred embodiments of theinvention include all 11-beta-aryl steroid backbone derivatives becausethese compounds are devoid of progesterone receptor (PR) bindingactivity (Agarwal, FEBS 217:221-226, 1987). Another preferred embodimentcomprises an 11-beta phenyl-aminodimethyl steroid backbone derivative,i.e., mifepristone, which is both an effective anti-glucocorticoid andanti-progesterone agent. These compositions act as reversibly-bindingsteroid receptor antagonists. For example, when bound to a 11-betaphenyl-aminodimethyl steroid, the steroid receptor is maintained in aconformation that cannot bind its natural ligand, such as cortisol inthe case of GR (Cadepond, 1997, supra).

Synthetic 11-beta phenyl-aminodimethyl steroids include mifepristone,also known as RU486, or17-beta-hydroxy-11-beta-(4-dimethyl-aminophenyl)17-alpha-(1-propynyl)estra-4,9-dien-3-one).Mifepristone has been shown to be a powerful antagonist of both theprogesterone and glucocorticoid (GR) receptors. Another 11-betaphenyl-aminodimethyl steroids shown to have GR antagonist effectsincludes RU009 (RU39.009),11-beta-(4-dimethyl-aminoethoxyphenyl)-17-alpha-(propynyl-17beta-hydroxy-4,9-estradien-3-one) (see Bocquel, J. Steroid Biochem.Molec. Biol. 45:205-215, 1993). Another GR antagonist related to RU486is RU044 (RU43.044)17-beta-hydroxy-17-alpha-19-(4-methyl-phenyl)-androsta-4,9(11)-dien-3-one) (Bocquel, 1993, supra). See also Teutsch, Steroids38:651-665, 1981; U.S. Pat. Nos. 4,386,085 and 4,912,097.

One embodiment includes compositions containing the basic glucocorticoidsteroid structure which are irreversible anti-glucocorticoids. Suchcompounds include alpha-keto-methanesulfonate derivatives of cortisol,including cortisol-21-mesylate (4-pregnene-11-beta, 17-alpha,21-triol-3,20-dione-21-methane-sulfonate and dexamethasone-21-mesylate(16-methyl-9 alpha-fluoro-1,4-pregnadiene-11 beta, 17-alpha,21-triol-3,20-dione-21-methane-sulfonate). See Simons, J. SteroidBiochem. 24:25-32, 1986; Mercier, J. Steroid Biochem. 25:11-20, 1986;U.S. Pat. No. 4,296,206.

2. Modification of the 17-Beta Side Chain Group

Steroidal antiglucocorticoids which can be obtained by variousstructural modifications of the 17-beta side chain are also used in themethods of the invention. This class includes syntheticantiglucocorticoids such as dexamethasone-oxetanone, various 17,21-acetonide derivatives and 17-beta-carboxamide derivatives ofdexamethasone (Lefebvre, 1989, supra; Rousseau, Nature 279:158-160,1979).

3. Other Steroid Backbone Modifications

GR antagonists used in the various embodiments of the invention includeany steroid backbone modification which effects a biological responseresulting from a GR-agonist interaction. Steroid backbone antagonistscan be any natural or synthetic variation of cortisol, such as adrenalsteroids missing the C-19 methyl group, such as19-nordeoxycorticosterone and 19-norprogesterone (Wynne, Endocrinology107:1278-1280, 1980).

In general, the 11-beta side chain substituent, and particularly thesize of that substituent, can play a key role in determining the extentof a steroid's antiglucocorticoid activity. Substitutions in the A ringof the steroid backbone can also be important. 17-hydroxypropenyl sidechains generally decrease antiglucocorticoid activity in comparison to17-propinyl side chain containing compounds.

Additional glucocorticoid receptor antagonists known in the art andsuitable for practice of the invention include21-hydroxy-6,19-oxidoprogesterone (see Vicent, Mol. Pharm. 52:749-753,1997); ORG 31710,(6β,11β3,17β)-11-(4-(dimethyl-amino)phenyl)-6-methyl-4′,5′-dihydro[estra-4,9-diene-17,2′(3H)-furan]-3-one,(see Mizutani, J Steroid Biochem Mol Biol 42(7):695-704, 1992); ORG34517,(11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)e-stra-4,9-dien-3-one,as disclosed in Hoyberg et al., Int'l J. of Neuro-psychopharmacology,5:Supp. 1, S148 (2002); ORG 33628,[(11β,17α)-11-(4-acetylphenyl)-17,23-epoxy-19,24-dinorchola-4,-9,20-trien-3-one];ORG 31806,[(7β,11β,17β)-11-(4-(dimethylamino)phenyl)-7-Me-4′,5′-dihydrospiro(oestra-4,9-diene-17,2′(3′H)-furan)-3-one]-;ORG 34116, (11β,17α)-11,21-Bis[4-(dimethylamino)phenyl]-17-hydroxy-19-norpregna-4,9,dien-20-yn-3-one;ORG 34850,(11b,17a)-11-[4-(dimethylamino)phenyl]-17-hydroxy-21-[4-(methylsulfonyl)phenyl-19-norpregna-4,9-dien-20-yn-3-one,and related compounds disclosed in U.S. Pat. No. 5,741,787; RU43044,(17β-hydroxy-11β-4-[methyl]-[1-methylethyl]aminophenyl/-17α-[prop-1-ynyl]estra-4-9-diene-3-one(“RU40555”, see Kim, J Steroid Biochem Mol Biol. 67(3):213-22, 1998),RU28362, and ZK98299.

B. Non-Steroidal Anti-Glucocorticoids as Antagonists

Non-steroidal glucocorticoid antagonists are also used in the methods ofthe invention to inhibit or reverse IL-2-induced depression. Theseinclude synthetic mimetics and analogs of proteins, including partiallypeptidic, pseudopeptidic and non-peptidic molecular entities. Forexample, oligomeric peptidomimetics useful in the invention include(alpha-beta-unsaturated) peptidosulfonamides, N-substituted glycinederivatives, oligo carbamates, oligo urea peptidomimetics,hydrazinopeptides, oligosulfones and the like (see, e.g., Amour, Int. J.Pept. Protein Res. 43:297-304, 1994; de Bont, Bioorganic & MedicinalChem. 4:667-672, 1996). The creation and simultaneous screening of largelibraries of synthetic molecules can be carried out using well-knowntechniques in combinatorial chemistry, for example, see van Breemen,Anal Chem 69:2159-2164, 1997; and Lam, Anticancer Drug Des 12:145-167,1997. Design of peptidomimetics specific for GR can be designed usingcomputer programs in conjunction with combinatorial chemistry(combinatorial library) screening approaches (Murray, J. ofComputer-Aided Molec. Design 9:381-395, 1995; Bohm, J. of Computer-AidedMolec. Design 10:265-272, 1996). Such “rational drug design” can helpdevelop peptide isomerics and conformers including cycloisomers,retro-inverso isomers, retro isomers and the like (as discussed inChorev, TibTech 13:438-445, 1995).

Examples of non-steroidal GR antagonists include ketoconazole,clotrimazole; N (triphenylmethyl)imidazole;N-([2-fluoro-9-phenyl]fluorenyl)imidazole;N-([2-pyridyl]diphenylmethyl)imidazole; N(2[4,4′,4″-trichlorotrityl]oxyethyl)morpholine;1-(2[4,4′,4″-trichlorotrityl]oxyethyl)-4 (2 hydroxyethyl)piperazinedimaleate; N-([4,4′,4″]-trichlorotrityl)imidazole; 9-(3-mercapto-1,2,4triazolyl)-9-phenyl-2,7-difluorofluorenone;1-(2-chlorotrityl)-3,5-dimethylpyrazole, 4(morpholinomethyl)-A-(2-pyridyl)benzhydrol;5-(5-methoxy-2-(N-methylcarbamoyl)-phenyl)dibenzosuberol;N-(2-chlorotrityl)-L-prolinol acetate;1-(2-chlorotrityl)-2-methylimidazole; 1 (2 chlorotrityl)-1,2,4-triazole;1,S-bis(4,4′,4″-trichlorotrityl)-1,2,4-triazole-3-thiol; and N ((2,6dichloro-3 methylphenyl)diphenyl)methylimidazole (see U.S. Pat. No.6,051,573); the GR antagonist compounds disclosed in U.S. Pat. No.5,696,127; the glucocorticoid receptor antagonists disclosed in Bradleyet al., J. Med. Chem. 45, 2417-2424 (2002), e.g.,4a(S)-Benzyl-2(R)-chloroethynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol(CP 394531) and4a(S)-Benzyl-2(R)-prop-1-ynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol(CP 409069); the compounds disclosed in PCT International ApplicationNo. WO 96/19458, which describes non-steroidal compounds which arehigh-affinity, highly selective antagonists for steroid receptors, suchas 6-substituted-1,2-dihydro-N protected-quinolines; and some κ opioidligands, such as the κ opioid compounds dynorphin-1,13 diamide, U50,488(trans-(1R,2R)-3,4-dichloro-N-methyl-N-[2-(1-pyrrolidinyl)cyclohexyl]benzeneacetamide),bremazocine and ethylketocyclazocine;4b(S)-benzyl-7(S)-hydroxy-7-(1-propynyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (pyridine-4-ylmethyl)amide CP-472555),4b(S)-benzyl-7(S)-hydroxy-7-(3,3,3-trifluoropropyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (2-methylpyridin-3-ylmethyl)amide and related compounds disclosedin WO 0066522 and in U.S. Pat App. 20040176595; octahydrophenanthrenylcarbamates disclosed in EP 1201649;oxadiazolylalkoxyoctahydrophenanthrenes disclosed in EP 1201660;octahydrophenanthrene hydrazines as disclosed in WO 2005/047254;modulators of the glucocorticoid receptor as disclosed in WO2004/005299; tricyclic compounds disclosed in WO 2005/011336 and WO2005/011337; Wieland-Miescher ketone derivatives disclosed in WO2003/011755; cyclopent[f]indazole and benz[f]indazole derivativesdisclosed WO 2004/075840; spirocyclic compounds disclosed in WO2004/093805; octahydro-2-H-naphtho[1,2,-f]indole-4-carboxamidederivatives disclosed in WO 2004/026248; cholic acid derivativesdisclosed in WO 2004/000869; dibenzopyran derivatives disclosed in WO2001/16128; 6H-dibenzo[b,d]pyran derivatives disclosed in U.S. Pat App.20020049322 and U.S. Pat App. 20030220332, substituted aminobenzenederivatives disclosed in WO 2002/064550; triphenylmethane derivativesdisclosed in U.S. Pat. No. 6,166,013; diphenyl ether derivativesdisclosed in WO 2001/047859 and WO 1999/63976; azadecalin derivativesdisclosed in WO 2005/070893; fused ring azadecalins disclosed in WO2005/087769; the modified pyrimidine compounds disclosed inPCT/US05/23675, and the non-specific opioid receptor ligand, naloxone,as disclosed in Evans et al., Endocrin., 141:2294 2300 (2000).

C. Identifying Specific Glucocorticoid Receptor Antagonists

Because any specific GR antagonist can be used to inhibit or reverseIL-2-induced depression in the methods of the invention, in addition tothe compounds and compositions described above, additional useful GRantagonists can be determined by the skilled artisan. A variety of suchroutine, well-known methods can be used and are described in thescientific and patent literature. They include in vitro and in vivoassays for the identification of additional GR antagonists. A fewillustrative examples are described below.

One assay that can be used to identify a GR antagonist of the inventionmeasures the effect of a putative GR antagonist on tyrosineamino-transferase activity in accordance with the method of Granner,Meth. Enzymol. 15:633, 1970. This analysis is based on measurement ofthe activity of the liver enzyme tyrosine amino-transferase (TAT) incultures of rat hepatoma cells (RHC). TAT catalyzes the first step inthe metabolism of tyrosine and is induced by glucocorticoids (cortisol)both in liver and hepatoma cells. This activity is easily measured incell extracts. TAT converts the amino group of tyrosine to 2-oxoglutaricacid. P-hydroxyphenylpyruvate is also formed. It can be converted to themore stable p-hydroxybenzaldehyde in an alkaline solution andquantitated by absorbance at 331 nm. The putative GR antagonist isco-administered with cortisol to whole liver, in vivo or ex vivo, orhepatoma cells or cell extracts. A compound is identified as a GRantagonist when its administration decreases the amount of induced TATactivity, as compared to control (i.e., only cortisol or GR agonistadded) (see also Shirwany, Biochem. Biophys. Acta 886:162-168, 1986).

Further illustrative of the many assays which can be used to identifycompositions utilized in the methods of the invention, in addition tothe TAT assay, are assays based on glucocorticoid activities in vivo.For example, assays that assess the ability of a putative GR antagonistto inhibit uptake of ³H-thymidine into DNA in cells which are stimulatedby glucocorticoids can be used. Alternatively, the putative GRantagonist can complete with ³H-dexamethasone for binding to a hepatomatissue culture GR (see, e.g., Choi, et al., Steroids 57:313-318, 1992).As another example, the ability of a putative GR antagonist to blocknuclear binding of ³H-dexamethasone-GR complex can be used (Alexandrovaet al., J. Steroid Biochem. Mol. Biol. 41:723-725, 1992). To furtheridentify putative GR antagonists, kinetic assays able to discriminatebetween glucocorticoid agonists and antagonists by means ofreceptor-binding kinetics can also be used (as described in Jones,Biochem J. 204:721-729, 1982).

In another illustrative example, the assay described by Daune, Molec.Pharm. 13:948-955, 1977; and in U.S. Pat. No. 4,386,085, can be used toidentify anti-glucocorticoid activity. Briefly, the thymocytes ofadrenalectomized rats are incubated in nutritive medium containingdexamethasone with the test compound (the putative GR antagonist) atvarying concentrations. ³H-uridine is added to the cell culture, whichis further incubated, and the extent of incorporation of radiolabel intopolynucleotide is measured. Glucocorticoid agonists decrease the amountof ³H-uridine incorporated. Thus, a GR antagonist will oppose thiseffect.

For additional compounds that can be utilized in the methods of theinvention and methods of identifying and making such compounds, see U.S.Pat. Nos. 4,296,206 (see above); 4,386,085 (see above); 4,447,424;4,477,445; 4,519,946; 4,540,686; 4,547,493; 4,634,695; 4,634,696;4,753,932; 4,774,236; 4,808,710; 4,814,327; 4,829,060; 4,861,763;4,912,097; 4,921,638; 4,943,566; 4,954,490; 4,978,657; 5,006,518;5,043,332; 5,064,822; 5,073,548; 5,089,488; 5,089,635; 5,093,507;5,095,010; 5,095,129; 5,132,299; 5,166,146; 5,166,199; 5,173,405;5,276,023; 5,380,839; 5,348,729; 5,426,102; 5,439,913; and 5,616,458;U.S. Pat. App. 20040176595, and WO 96/19458, which describesnon-steroidal compounds which are high-affinity, highly selectivemodulators (antagonists) for steroid receptors, such as6-substituted-1,2-dihydro N-1 protected quinolines.

The specificity of the antagonist for the GR relative to the MR can bemeasured using a variety of assays known to those of skill in the art.For example, specific antagonists can be identified by measuring theability of the antagonist to bind to the GR compared to the MR (see,e.g., U.S. Pat. Nos. 5,606,021; 5,696,127; 5,215,916; 5,071,773). Suchan analysis can be performed using either direct binding assay or byassessing competitive binding to the purified GR or MR in the presenceof a known antagonist. In an exemplary assay, cells that are stablyexpressing the glucocorticoid receptor or mineralocorticoid receptor(see, e.g., U.S. Pat. No. 5,606,021) at high levels are used as a sourceof purified receptor. The affinity of the antagonist for the receptor isthen directly measured. Those antagonists that exhibit at least a100-fold higher affinity, often 1000-fold, for the GR relative to the MRare then selected for use in the methods of the invention.

A GR-specific antagonist may also be defined as a compound that has theability to inhibit GR-mediated activities, but not MR-mediatedactivities. One method of identifying such a GR-specific antagonist isto assess the ability of an antagonist to prevent activation of reporterconstructs using transfection assays (see, e.g., Bocquel et al., J.Steroid Biochem Molec. Biol. 45:205-215, 1993; U.S. Pat. Nos. 5,606,021,5,929,058). In an exemplary transfection assay, an expression plasmidencoding the receptor and a reporter plasmid containing a reporter genelinked to receptor-specific regulatory elements are cotransfected intosuitable receptor-negative host cells. The transfected host cells arethen cultured in the presence and absence of a hormone, such as cortisolor an analog thereof, able to activate the hormone responsivepromoter/enhancer element of the reporter plasmid. Next the transfectedand cultured host cells are monitored for induction (i.e., the presence)of the product of the reporter gene sequence. Finally, the expressionand/or steroid binding-capacity of the hormone receptor protein (codedfor by the receptor DNA sequence on the expression plasmid and producedin the transfected and cultured host cells), is measured by determiningthe activity of the reporter gene in the presence and absence of anantagonist. The antagonist activity of a compound may be determined incomparison to known antagonists of the GR and MR receptors (see, e.g.,U.S. Pat. No. 5,696,127). Efficacy is then reported as the percentmaximal response observed for each compound relative to a referenceantagonist compound. A GR-specific antagonist is considered to exhibitat least a 100-fold, often 1000-fold or greater, activity towards the GRrelative to the MR.

V. AMELIORATING SYMPTOMS OF DEPRESSION ASSOCIATED WITH IL-2 THERAPYUSING GLUCOCORTICOID RECEPTOR ANTAGONISTS

Antiglucocorticoids, such as mifepristone, are formulated aspharmaceuticals to be used in the methods of the invention to inhibit orreverse IL-2-induced depression. Any composition or compound that canblock or interfere with the binding of cortisol or a cortisol analogueto a GR can be used as a pharmaceutical in the invention. Routine meansto determine GR antagonist drug regimens and formulations to practicethe methods of the invention are well described in the patent andscientific literature, and some illustrative examples are set forthbelow.

A. Glucocorticoid Receptor Antagonists as Pharmaceutical Compositions

The GR antagonists used in the methods of the invention can beadministered by any means known in the art, e.g., parenterally,topically, orally, or by local administration, such as by aerosol ortransdermally. The methods of the invention provide for prophylacticand/or therapeutic treatments. The GR antagonists as pharmaceuticalformulations can be administered in a variety of unit dosage formsdepending upon the condition or disease and the degree of severity, thegeneral medical condition of each patient, the resulting preferredmethod of administration and the like. Details on techniques forformulation and administration are well described in the scientific andpatent literature, see, e.g., the latest edition of Remington'sPharmaceutical Sciences, Mack Publishing Co, Easton Pa. Therapeuticallyeffective amounts of glucocorticoid blockers suitable for practice ofthe method of the invention may range from about 0.5 to about 25milligrams per kilogram (mg/kg). A person of ordinary skill in the artwill be able without undue experimentation, having regard to that skilland this disclosure, to determine a therapeutically effective amount ofa particular glucocorticoid blocker compound for practice of thisinvention.

In general, glucocorticoid blocker compounds may be administered aspharmaceutical compositions by any method known in the art foradministering therapeutic drugs. Compositions may take the form oftablets, pills, capsules, semisolids, powders, sustained releaseformulations, solutions, suspensions, elixirs, aerosols, or any otherappropriate compositions; and comprise at least one compound of thisinvention in combination with at least one pharmaceutically acceptableexcipient. Suitable excipients are well known to persons of ordinaryskill in the art, and they, and the methods of formulating thecompositions, may be found in such standard references as Remington'sPharmaceutical Sciences. Suitable liquid carriers, especially forinjectable solutions, include water, aqueous saline solution, aqueousdextrose solution, and glycols.

Aqueous suspensions of the invention contain a GR antagonist inadmixture with excipients suitable for the manufacture of aqueoussuspensions. Such excipients include a suspending agent, such as sodiumcarboxymethylcellulose, methylcellulose, hydroxypropylmethylcellulose,sodium alginate, polyvinylpyrrolidone, gum tragacanth and gum acacia,and dispersing or wetting agents such as a naturally occurringphosphatide (e.g., lecithin), a condensation product of an alkyleneoxide with a fatty acid (e.g., polyoxyethylene stearate), a condensationproduct of ethylene oxide with a long chain aliphatic alcohol (e.g.,heptadecaethylene oxycetanol), a condensation product of ethylene oxidewith a partial ester derived from a fatty acid and a hexitol (e.g.,polyoxyethylene sorbitol mono-oleate), or a condensation product ofethylene oxide with a partial ester derived from fatty acid and ahexitol anhydride (e.g., polyoxyethylene sorbitan mono-oleate). Theaqueous suspension can also contain one or more preservatives such asethyl or n-propyl p-hydroxybenzoate, one or more coloring agents, one ormore flavoring agents and one or more sweetening agents, such assucrose, aspartame or saccharin. Formulations can be adjusted forosmolarity.

Oil suspensions can be formulated by suspending a GR antagonist in avegetable oil, such as arachis oil, olive oil, sesame oil or coconutoil, or in a mineral oil such as liquid paraffin; or a mixture of these.The oil suspensions can contain a thickening agent, such as beeswax,hard paraffin or cetyl alcohol. Sweetening agents can be added toprovide a palatable oral preparation, such as glycerol, sorbitol orsucrose. These formulations can be preserved by the addition of anantioxidant such as ascorbic acid. As an example of an injectable oilvehicle, see Minto, J. Pharmacol. Exp. Ther. 281:93-102, 1997. Thepharmaceutical formulations of the invention can also be in the form ofoil-in-water emulsions. The oily phase can be a vegetable oil or amineral oil, described above, or a mixture of these. Suitableemulsifying agents include naturally-occurring gums, such as gum acaciaand gum tragacanth, naturally occurring phosphatides, such as soybeanlecithin, esters or partial esters derived from fatty acids and hexitolanhydrides, such as sorbitan mono-oleate, and condensation products ofthese partial esters with ethylene oxide, such as polyoxyethylenesorbitan mono-oleate. The emulsion can also contain sweetening agentsand flavoring agents, as in the formulation of syrups and elixirs. Suchformulations can also contain a demulcent, a preservative, or a coloringagent.

Glucocorticoid blocker pharmaceutical formulations can be preparedaccording to any method known to the art for the manufacture ofpharmaceuticals. Such drugs can contain sweetening agents, flavoringagents, coloring agents and preserving agents. Any glucocorticoidblocker formulation can be admixtured with nontoxic pharmaceuticallyacceptable excipients which are suitable for manufacture.

Typically, glucocorticoid blocker compounds suitable for use in thepractice of this invention will be administered orally. The amount of acompound of this invention in the composition may vary widely dependingon the type of composition, size of a unit dosage, kind of excipients,and other factors well known to those of ordinary skill in the art. Ingeneral, the final composition may comprise from 0.000001 percent byweight (% w) to 10% w of the glucocorticoid blocker compounds,preferably 0.00001% w to 1% w, with the remainder being the excipient orexcipients. For example, the GR antagonist mifepristone is given orallyin tablet form, with dosages in the range of between about 0.5 and 25mg/kg, more preferably between about 0.75 mg/kg and 15 mg/kg, mostpreferably about 10 mg/kg.

Pharmaceutical formulations for oral administration can be formulatedusing pharmaceutically acceptable carriers well known in the art indosages suitable for oral administration. Such carriers enable thepharmaceutical formulations to be formulated in unit dosage forms astablets, pills, powder, dragees, capsules, liquids, lozenges, gels,syrups, slurries, suspensions, etc., suitable for ingestion by thepatient. Pharmaceutical preparations for oral use can be obtainedthrough combination of glucocorticoid blocker compounds with a solidexcipient, optionally grinding a resulting mixture, and processing themixture of granules, after adding suitable additional compounds, ifdesired, to obtain tablets or dragee cores. Suitable solid excipientsare carbohydrate or protein fillers and include, but are not limited tosugars, including lactose, sucrose, mannitol, or sorbitol; starch fromcorn, wheat, rice, potato, or other plants; cellulose such as methylcellulose, hydroxypropylmethyl-cellulose or sodiumcarboxymethylcellulose; and gums including arabic and tragacanth; aswell as proteins such as gelatin and collagen. If desired,disintegrating or solubilizing agents may be added, such as thecross-linked polyvinyl pyrrolidone, agar, alginic acid, or a saltthereof, such as sodium alginate.

The GR antagonists of this invention can also be administered in theform of suppositories for rectal administration of the drug. Theseformulations can be prepared by mixing the drug with a suitablenon-irritating excipient which is solid at ordinary temperatures butliquid at the rectal temperatures and will therefore melt in the rectumto release the drug. Such materials are cocoa butter and polyethyleneglycols.

The GR antagonists of this invention can also be administered by inintranasal, intraocular, intravaginal, and intrarectal routes includingsuppositories, insufflation, powders and aerosol formulations (forexamples of steroid inhalants, see Rohatagi, J. Clin. Pharmacol.35:1187-1193, 1995; Tjwa, Ann. Allergy Asthma Immunol. 75:107-111,1995).

The GR antagonists of the invention can be delivered transdermally, by atopical route, formulated as applicator sticks, solutions, suspensions,emulsions, gels, creams, ointments, pastes, jellies, paints, powders,and aerosols.

The GR antagonists of the invention can also be delivered asmicrospheres for slow release in the body. For example, microspheres canbe administered via intradermal injection of drug (e.g.,mifepristone)-containing microspheres, which slowly releasesubcutaneously (see Rao, J. Biomater Sci. Polym. 7:623-645, 1995; asbiodegradable and injectable gel formulations (see, e.g., Gao Pharm.Res. 12:857-863, 1995); or, as microspheres for oral administration(see, e.g., Eyles, J. Pharm. Pharmacol. 49:669-674, 1997). Bothtransdermal and intradermal routes afford constant delivery for weeks ormonths.

The GR antagonist pharmaceutical formulations of the invention can beprovided as a salt and can be formed with many acids, including but notlimited to hydrochloric, sulfuric, acetic, lactic, tartaric, malic,succinic, etc. Salts tend to be more soluble in aqueous or otherprotonic solvents that are the corresponding free base forms. In othercases, the preferred preparation may be a lyophilized powder in 1 mM-50mM histidine, 0.1%-2% sucrose, 2%-7% mannitol at a pH range of 4.5 to5.5, that is combined with buffer prior to use

In another embodiment, the GR antagonist formulations of the inventionare useful for parenteral administration, such as intravenous (IV)administration. The formulations for administration will commonlycomprise a solution of the GR antagonist (e.g., mifepristone) dissolvedin a pharmaceutically acceptable carrier. Among the acceptable vehiclesand solvents that can be employed are water and Ringer's solution, anisotonic sodium chloride. In addition, sterile fixed oils canconventionally be employed as a solvent or suspending medium. For thispurpose any bland fixed oil can be employed including synthetic mono- ordiglycerides. In addition, fatty acids such as oleic acid can likewisebe used in the preparation of injectables. These solutions are sterileand generally free of undesirable matter. These formulations may besterilized by conventional, well known sterilization techniques. Theformulations may contain pharmaceutically acceptable auxiliarysubstances as required to approximate physiological conditions such aspH adjusting and buffering agents, toxicity adjusting agents, e.g.,sodium acetate, sodium chloride, potassium chloride, calcium chloride,sodium lactate and the like. The concentration of GR antagonist in theseformulations can vary widely, and will be selected primarily based onfluid volumes, viscosities, body weight, and the like, in accordancewith the particular mode of administration selected and the patient'sneeds. For IV administration, the formulation can be a sterileinjectable preparation, such as a sterile injectable aqueous oroleaginous suspension. This suspension can be formulated according tothe known art using those suitable dispersing or wetting agents andsuspending agents. The sterile injectable preparation can also be asterile injectable solution or suspension in a nontoxicparenterally-acceptable diluent or solvent, such as a solution of1,3-butanediol.

In another embodiment, the GR antagonist formulations of the inventioncan be delivered by the use of liposomes which fuse with the cellularmembrane or are endocytosed, i.e., by employing ligands attached to theliposome, or attached directly to the oligonucleotide, that bind tosurface membrane protein receptors of the cell resulting in endocytosis.By using liposomes, particularly where the liposome surface carriesligands specific for target cells, or are otherwise preferentiallydirected to a specific organ, one can focus the delivery of the GRantagonist into the target cells in vivo. (See, e.g., Al-Muhammed, J.Microencapsul. 13:293-306, 1996; Chonn, Curr. Opin. Biotechnol.6:698-708, 1995; Ostro, Am. J. Hosp. Pharm. 46:1576-1587, 1989).

B. Determining Dosing Regimens for Glucocorticoid Receptor Antagonists

The methods of this invention inhibit or reverse IL-2-induceddepression. The amount of GR antagonist adequate to accomplish this isdefined as a “therapeutically effective dose”. The dosage schedule andamounts effective for this use, i.e., the “dosing regimen,” will dependupon a variety of factors, including the type of the IL-2 medication thepatient is using, the severity of IL-2-induced depression that hasalready occurred, the patient's physical status, age and the like. Incalculating the dosage regimen for a patient, the mode of administrationalso is taken into consideration.

The dosage regimen also takes into consideration pharmacokineticsparameters well known in the art, i.e., the GR antagonists' rate ofabsorption, bioavailability, metabolism, clearance, and the like (see,e.g., Hidalgo-Aragones, J. Steroid Biochem. Mol. Biol. 58:611-617, 1996;Groning, Pharmazie 51:337-341, 1996; Fotherby, Contraception 54:59-69,1996; Johnson, J. Pharm. Sci. 84:1144-1146, 1995; Rohatagi, Pharmazie50:610-613, 1995; Brophy, Eur. J. Clin. Pharmacol. 24:103-108, 1983; thelatest Remington's, supra). For example, in one study, less than 0.5% ofthe daily dose of mifepristone was excreted in the urine; the drug boundextensively to circulating albumin (see Kawai, supra, 1989). The stateof the art allows the clinician to determine the dosage regimen for eachindividual patient, GR antagonist and disease or condition treated. Asan illustrative example, the guidelines provided below for mifepristonecan be used as guidance to determine the dosage regiment, i.e., doseschedule and dosage levels, of any GR antagonist administered whenpracticing the methods of the invention.

Single or multiple administrations of GR antagonist formulations can beadministered depending on the dosage and frequency as required andtolerated by the patient. The formulations should provide a sufficientquantity of active agent, e.g., mifepristone, to effectively inhibit orreverse the symptoms of depression induced by IL-2 medications. Forexample, a typical preferred pharmaceutical formulation for oraladministration of mifepristone would be about 5 to 15 mg/kg of bodyweight per patient per day, more preferably between about 8 to about 12mg/kg of body weight per patient per day, most preferably 10 mg/kg ofbody weight per patient per day, although dosages of between about 0.5to about 25 mg/kg of body weight per day may be used in the practice ofthe invention. Lower dosages can be used, particularly when the drug isadministered to an anatomically secluded site, such as the cerebralspinal fluid (CSF) space, in contrast to administration orally, into theblood stream, into a body cavity or into a lumen of an organ.Substantially higher dosages can be used in topical administration.Actual methods for preparing parenterally administrable GR antagonistformulations will be known or apparent to those skilled in the art andare described in more detail in such publications as Remington's, supra.See also Nieman, In “Receptor Mediated Antisteroid Action,” Agarwal, etal., eds., De Gruyter, N.Y., 1987.

EXAMPLES

The following examples are offered to illustrate, but not to limit theclaimed invention.

Example 1 Use of Mifepristone to Ameliorate Symptoms of Depression in aPatient Undergoing IL-2 Therapy

The following example demonstrates how to practice the methods of theinvention.

Patient Selection

Individuals who are to begin or are currently undergoing IL-2 therapy.The patient typically has normal levels of cortisol for his or her age.

Dosage Regimen and Administration of Mifepristone

The glucocorticoid receptor (GR) antagonist, mifepristone, is used inthis study. It is administered in dosages of 200 mg daily. Individualswill be given 200 mg of mifepristone daily for six months and evaluatedas described below. Dosages will be adjusted if necessary and furtherevaluations will be performed periodically throughout treatment.

Mifepristone tablets are available from commercial sources such asShanghai Hua Lian Pharmaceuticals Co., Ltd., Shanghai, China.

Assessing Amelioration of Symptoms of Depression

To delineate and assess the effectiveness of mifepristone inameliorating the symptoms of depression, a patient who is suffering fromor is susceptible to depression associated with IL-2 therapy isexamined, both before and after receiving mifepristone, for the presenceand/or severity of depression symptoms. The detailed examination methodsand criteria for assessing the condition of depression can be found in,e.g., Diagnostic and Statistical Manual of Mental Disorders, FourthEdition (DSM-IV).

It is understood that the examples and embodiments described herein arefor illustrative purposes only and that various modifications or changesin light thereof will be suggested to persons skilled in the art and areto be included within the spirit and purview of this application andscope of the claims. All publications, patents, and patent applicationscited herein are hereby incorporated by reference in their entirety forall purposes.

1. A method for ameliorating the symptoms of depression in a patientwith normal levels of cortisol taking interleukin-2 (IL-2), comprisingthe step of administering to the patient an effective amount of aspecific glucocorticoid receptor antagonist, with the proviso that thepatient is not clinically depressed at the time IL-2 therapy iscommenced, and is not otherwise in need of treatment with aglucocorticoid receptor antagonist.
 2. The method of claim 1, whereinthe glucocorticoid receptor antagonist is administered to the patientcoextensively with IL-2.
 3. The method of claim 2, wherein theglucocorticoid receptor antagonist is administered to the patient duringthe entire time when the patient is taking IL-2.
 4. The method of claim1, wherein the glucocorticoid receptor antagonist is administered to thepatient taking IL-2 in conjunction with other treatment methods.
 5. Themethod of claim 1, wherein the glucocorticoid receptor antagonist isadministered via intravaginal or intrarectal routes.
 6. The method ofclaim 5, wherein the glucocorticoid receptor antagonist is administeredby suppositories.
 7. The method of claim 1, wherein the glucocorticoidreceptor antagonist comprises a steroid compound.
 8. The method of claim7, wherein the glucocorticoid receptor antagonist has a modifiedcortisol steroid backbone selected from the group consisting of removalof the 11-β-hydroxy group, aryl substitution of the 11-β-hydroxy group,11-β-phenyl-aminodimethyl steroids, 17-β-side chain modifications,alpha-keto-methane-sulfonate derivatives of cortisol, and androgen typesteroids.
 9. The method of claim 7, wherein the glucocorticoid receptorantagonist is selected from the group consisting ofdexamethasone-oxetanone,4-pregnene-11-beta,17-alpha,21-triol-3,20-dione-21-methane-sulfonate,16-methyl-9alpha-fluoro-1,4-pregnadiene-11β,17-alpha,21-triol-3,20-dione-21-methane-sulfonate,11-β-(4-dimethyl-aminoethoxyphenyl)-17-alpha-(propynyl-17-beta-hydroxy-4,9-estradien-3-one,and17-β-hydroxy-11-β-(4-dimethyl-aminophenyl)17-alpha-(1-propynyl)estra-4,9-dien-3-one.10. The method of claim 7, wherein the glucocorticoid receptorantagonist is selected from the group consisting of(6β,11β,17β)-11-(4-(dimethyl-amino)phenyl)-6-methyl-4′,5′-dihydro[estra-4,9-diene-17,2′(3H′)-furan]-3-one,(11β,17β)-11-(1,3-benzodioxol-5-yl)-17-hydroxy-17-(1-propynyl)e-stra-4,9-dien-3-one,(11β,17α)-11-(4-acetylphenyl)-17,23-epoxy-19,24-dinorchola-4,-9,20-trien-3-one,(7β,11β,17β)-11-(4-(dimethylamino)phenyl)-7-Me-4′,5′-dihydrospiro(oestra-4,9-diene-17,2′(3′H)-furan)-3-one]-,(11β,17α)-11,21-Bis[4-(dimethylamino)phenyl]-17-hydroxy-19-norpregna-4,9,dien-20-yn-3-one,and(11β,17α)-11-[4-(dimethylamino)phenyl]-17-hydroxy-21-[4-(methylsulfonyl)phenyl-19-norpregna-4,9-dien-20-yn-3-one11. The method of claim 7, wherein the glucocorticoid receptorantagonist comprises a steroidal skeleton with at least onephenyl-containing moiety in the 11-beta position of the steroidalskeleton.
 12. The method of claim 11, wherein the phenyl-containingmoiety in the 11-beta position of the steroidal skeleton is adimethylaminophenyl moiety.
 13. The method of claim 12, wherein theglucocorticoid receptor antagonist comprises mifepristone.
 14. Themethod of claim 11, wherein the glucocorticoid receptor antagonist isselected from the group consisting of RU009 and RU044.
 15. The method ofclaim 1, wherein the glucocorticoid receptor antagonist comprises anon-steroidal compound.
 16. The method of claim 15, wherein theglucocorticoid receptor antagonist comprises a modified pyrimidinecompound
 17. The method of claim 15, wherein the glucocorticoid receptorantagonist is4b(S)-benzyl-7(S)-hydroxy-7-(1-propynyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (pyridine-4-ylmethyl)amide.
 18. The method of claim 15, wherein theglucocorticoid receptor antagonist is4b(S)-benzyl-7(S)-hydroxy-7-(3,3,3-trifluoropropyl)-4b,5,6,7,8,8a(R),9,10-octahydrophenanthrene-2-carboxylicacid (2-methylpyridin-3-ylmethyl)amide.
 19. The method of claim 15,wherein the glucocorticoid receptor antagonist is selected from thegroup consisting of 1-(o-chloro-alpha,alpha-diphenylbenzyl)imidazole,N(triphenylmethyl)imidazole, N-([2-fluoro-9-phenyl]fluorenyl)imidazole,N-([2-pyridyl]diphenylmethyl)imidazole,N-([4,4′,4″]-trichlorotrityl)imidazole, and N((2,6dichloro-3-methylphenyl)diphenyl)methylimidazol
 20. The method of claim15, wherein the glucocorticoid receptor antagonist is selected from thegroup consisting of 6-substituted-1,2-dihydro-N protected-quinolines,octahydrophenanthrenyl carbamates,oxadiazolylalkoxyoctahydrophenanthrenes, and octahydrophenanthrenehydrazines.
 21. The method of claim 15, wherein the glucocorticoidreceptor antagonist is selected from the group consisting ofoctahydro-2-H-naphthol[1,2,-f]indole-4 carboxamide,cyclopent[f]indazole, and benz[f]indazole.
 22. The method of claim 15,wherein the glucocorticoid receptor antagonist is selected from thegroup consisting of 6H-dibenzo[b,d]pyran derivatives, substitutedaminobenzene derivatives, triphenylmethane derivatives, diphenyl etherderivatives, and modified pyrimidine compounds.
 23. The method of claim15, wherein the glucocorticoid receptor antagonist is selected from thegroup consisting of 1-(2-chlorotrityl)-2-methylimidazole,N-(2-chlorotrityl)-L-prolinol acetate,1-(2-chlorotrityl)-1,2,4-triazole, and1-(2-chlorotrityl)-3,5-dimethylpyrazole.
 24. The method of claim 15,wherein the glucocorticoid receptor antagonist is selected from thegroup consisting ofcis-1-acetyl-4-(4-((2-(2,4-dichlorophenyl)-2-(1H-imidazol-1-ylmethyl)-1,3-dioxolan-4-yl)methoxy)phenyl)piperazine,N-(2[4,4′,4″-trichlorotrityl]oxyethyl)morpholine,1-(2[4,4′,4″-trichlorotrityl]oxyethyl)-4(2-hydroxyethyl)piperazinedimaleate, 4-(morpholinomethyl)-A-(2-pyridyl)benzhydrol, and1,S-bis(4,4′,4″-trichlorotrityl)-1,2,4-triazole-3-thiol.
 25. The methodof claim 15, wherein the glucocorticoid receptor antagonist is selectedfrom the group consisting of 9-(3-mercapto-1,2,4triazolyl)-9-phenyl-2,7-difluorofluorenone,5-(5-methoxy-2-(N-methylcarbamoyl)-phenyl)dibenzosuberol,4a(S)-benzyl-2(R)-chloroethynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol,and4a(S)-benzyl-2(R)-prop-1-ynyl-1,2,3,4,4a,9,10,10a(R)-octahydro-phenanthrene-2,7-diol.26. The method of claim 15, wherein the glucocorticoid receptorantagonist is an azadecalin compound.
 27. The method of claim 15,wherein the glucocorticoid receptor antagonist is a fused ringazadecalin compound.
 28. The method of claim 1, wherein theglucocorticoid receptor antagonist is administered once per day.
 29. Themethod of claim 1, wherein the glucocorticoid receptor antagonist isadministered in an amount of between 0.5 mg and 20 mg per kg of bodyweight per day.
 30. The method of claim 29, wherein the glucocorticoidreceptor antagonist is administered in an amount of between about 1 mgand 10 mg per kg of body weight per day.
 31. The method of claim 30,wherein the glucocorticoid receptor antagonist is administered in anamount of between 1 mg and 4 mg per kg of body weight per day.
 32. Themethod of claim 1, wherein the glucocorticoid receptor antagonist isadministered orally.
 33. The method of claim 1, wherein theglucocorticoid receptor antagonist is administered by a transdermalapplication, by a nebulized suspension, by an aerosol spray, or byinjection.